Child Oral Health in Hounslow

Child Oral Health in Hounslow Introduction With the 2012 Health and Social Care Act the responsibilities for commissioning programmes to improve children s oral health changed and the commissioning of (primary, community and secondary care) dental services moved to NHS England. From the 1 st April 2013, Local authorities are now statutorily required to assess their local population s oral health needs, develop oral health strategies and commission or provide oral health improvement programmes i. They must also provide or commission oral health surveys as part of the Dental Public Health Intelligence Programme ii. Local authorities can use these oral health surveys to: Assess and monitor oral health needs in their local population Plan and evaluate oral health improvement programmes Plan and evaluate NHS dental services Report and monitor the effects of any local water fluoridation schemes covering their local population Local authorities are also responsible for making proposals regarding water fluoridation schemes and for conducting public consultations in relation to these iii. Impacts Good oral health is an integral part of general health and well-being. Oral health affects people physically and psychologically and influences how they grow, enjoy life, look, speak, chew, taste food and socialise, as well as their feelings of social well-being. iv Poor oral health can affect an individual s ability to sleep, eat, speak, play concentrating and socialise with other children v, thereby affecting health-related quality of life with individual and societal consequences. vi Often dental treatment for young children (such as extractions of decayed teeth) may only be done under general anaesthetic, which is both distressing for the families concerned and expensive. Other impacts include pain, infections, poor diet, and impaired nutrition and growth. According to the Global Burden of Disease Study in 2010, five to nine year-old children in the UK experienced the most disability caused by poor oral health vii. An average of 2.24 hours of children s healthy life were lost because of poor oral health exceeding the level of disability associated with vision loss, hearing loss and diabetes viii. Tooth decay is the most common oral disease affecting children and young people in England, yet it is largely preventable.the determinants of oral diseases are known they are the risk factors common to a number of chronic diseases: diet, hygiene, smoking, alcohol, risky behaviours causing injuries, and stress. ix Increased consumption of sugary food and drinks, poor oral hygiene and lack of exposure to fluoride are particular factors which contribute to poor oral health. The oral health of children has been identified by the Government as a priority area within public health x,xi,xii and a new public health outcome measure has been developed around tooth decay in children aged 5 years xiii. This recognises the need for local areas to focus on and prioritise oral health and oral health improvement initiatives (which can be very effective in preventing tooth decay). In line with this, in 201, an evidence-based Child Oral Health Improvement Strategy was developed for the eight North West London boroughs. xiv

Child oral health It is well recognised that oral health is an important part of general health and wellbeing. Despite improvements in children s oral health over the past 30 years, tooth decay remains a significant public health problem, particularly among young children in disadvantaged communities, with the associated dental problems of toothache, abscesses and extractions. In England, regular oral health surveys are carried out and 5 year olds are surveyed most frequently. Child oral health in Hounslow London boroughs in 2012* number of decayed, missing and filled teeth (dmft) in five-year-old children *Bexley, Croydon and Greenwich did not participate in the National Dental Epidemiology Programme in 2012; Data suppression for City and London due to low numbers Enfield Brent Tower Hamlets Haringey Westminster Ealing Camden Newham Hillingdon Harrow Islington Kensington and Chelsea Barking and Dagenham London Hackney Waltham Forest Hammersmith and Fulham Hounslow Redbridge Merton Barnet Wandsworth Lambeth Sutton Southwark Lewisham Havering Kingston upon Thames Bromley Richmond upon Thames 1.23 1.08 0.00 1.00 2.00 3.00 Average number of decayed, missing and filled teeth (dmft) Error bars represent 95% confidence

Percentage of five-year-old children in London boroughs who have had tooth decay experience in 2012* *Bexley, Croydon and Greenwich did not participate in the National Dental Epidemiology Programme in 2012; Data suppression for City and London due to low numbers Tower Hamlets Brent Enfield Ealing Westminster Newham Hillingdon Haringey Hounslow Camden Harrow Barking and Dagenham London Hackney Islington Kensington and Chelsea Merton Wandsworth Hammersmith and Fulham Sutton Redbridge Waltham Forest Barnet Lambeth Southwark Lewisham Bromley Havering Kingston upon Thames Richmond upon Thames 46% 46% 44% 42% 40% 39% 38% 38% 36% 36% 35% 35% 33% 31% 30% 30% 29% 29% 28% 28% 27% 27% 25% 24% 22% 22% 22% 20% 19% 17% Map of London Boroughs showing % 5 year old children with decay experience compared to London average 0% 10% 20% 30% 40% 50% Percentage of children who experienced tooth decay

Percentage of five-year-old children in London boroughs who have one or more untreated decayed tooth in 2012* *Bexley, Croydon and Greenwich did not participate in the National Dental Epidemiology Programme in 2012; Data suppression for City and London due to low numbers Tower Hamlets Brent Ealing Enfield Haringey Hillingdon Newham Westminster Harrow Barking and Dagenham Hounslow Camden London Hackney Wandsworth Merton Kensington and Chelsea Hammersmith and Fulham Waltham Forest Sutton Barnet Redbridge Islington Lambeth Southwark Bromley Havering Kingston upon Thames Richmond upon Thames Lewisham 41.2% 39.2% 37.5% 37.4% 35.7% 35.6% 35.5% 35.4% 31.2% 31.1% 30.6% 30.3% 28.8% 28.1% 26.0% 25.2% 24.4% 24.0% 23.2% 22.5% 22.4% 22.4% 22.2% 19.9% 18.9% 18.3% 17.5% 14.8% 14.3% 14.1% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% Map of London Boroughs with % 5 year old children with active decay

Twelve out of 29 London boroughs had a higher percentage of five-year-old children who had experienced tooth decay in 2012 than the London average (33%) and included Hounslow at 36%. Five year old children living in Hounslow are twice as likely to have decay experience as those in Richmond (17%). Twelve out of 29 London boroughs had a higher percentage of five-year-old children who had one or more untreated decayed tooth in 2012 than the London average (29%) and included Hounslow at 31%. The two most recent surveys, carried out in 2008 and 2012 allow comparisons over time for the first time. In Hounslow, the average dmft in 5-year-old children was 3.55 in 2008 and 2.96 in 2012 ie there has been a slight improvement in the severity of disease between 2008 and 2012. However, the prevalence of decay experience has increased between the 2 surveys. ie. In 2008, 33% of 5 year old children in Hounslow had one or more decayed, missing or filled tooth whereas in 2012, 36% of 5 year old children in Hounslow had one or more decayed, missing or filled tooth. At aged 5 years, untreated dental decay is responsible for the majority of the disease experience. The maps show there were clear geographical variations in tooth decay experience in five year old children across London in 2012, with Hounslow amongst the highest percentage of five-year-old children had experienced tooth decay and had untreated decayed teeth. Hounslow is amongst 10 out of 29 London boroughs had a higher percentage of five-year-old children who had an abscess/sepsis in 2012 than the London average (2.2%), Hounslow (2.4%). Barking and Dagenham Newham Haringey Ealing Enfield Harrow Richmond upon Thames Merton Havering Hounslow London Bromley Westminster Hackney Tower Hamlets Hillingdon Southwark Wandsworth Sutton Camden Barnet Kensington and Chelsea Brent Lambeth Hammersmith and Fulham Kingston upon Thames Waltham Forest Redbridge Lewisham Islington 1.7% 1.5% 1.1% 1.0% 1.0% 1.0% 0.8% 0.6% 0.4% 0.4% 0.4% 0.0% 0.0% 0.0% 0.0% 2.7% 2.7% 2.4% 2.2% 2.2% 2.1% 2.1% 1.7% 4.5% 4.2% 4.1% 3.9% 3.6% 3.1% 3.0% 0.0% 10.0%

Number of Admissions Child Hospital Admissions Dental decay is the most common reason for hospital admissions in children aged over 1 year, despite being a preventable disease. In Hounslow in 2012/13 there were 416 admissions due to dental decay and in the 5-9 year olds this accounted for 19% of all admissions. Tooth extractions under GA are not only potentially avoidable for most children, but also costly. The cost of child hospital admissions due to dental decay in Hounslow for children aged 1-18 years in 2012/13 was 262,037. 450 400 350 300 250 200 150 100 50 0 Top causes of childhood hospital admissions (1-18 year olds) in Hounslow in 2012/13 (Source: SUS) 1-4 5-9 Dental caries is the top cause for child hospital admissions total of 416 (1-18 year olds) In 2012/13, for 5-9 year olds there were 231 (19%) admissions due to dental caries Claire Robertson, Inequalities People living in deprived communities consistently have poorer oral health than people living in richer communities. These inequalities in oral health run from the top to the bottom of the socioeconomic ladder creating a social gradient. Some vulnerable groups have poorer oral health. Many general health conditions and oral diseases share common risk factors such as smoking, alcohol misuse and poor diet. Like many childhood diseases, there was a positive correlation between tooth decay experience in 2012 and socio-economic deprivation. London boroughs with higher Index of

Multiple Deprivation (IMD) 2010 scores had a higher average number of untreated decayed, filled and missing teeth (dmft) in five-year-old children in 2012 The correlation between decayed, missing and filled teeth (dmft) at aged 5 years 2012 and IMD in London boroughs, showing the inequalities across London Summary of Child Oral Health in Hounslow: o o o o o o Children aged 5 years in Hounslow have on average 1.08 decayed, missing or filled teeth (dmft) 36% 5 year olds have decay experience 5 year olds with experience of decay have on average 3 decayed missing or filled teeth The care index for Hounslow 5 year olds was 12%, indicating that only 12% of teeth which are likely to have needed restorative treatment have received it (the remainder being left untreated or extracted) (compared to 13% in London and 11% England) Dental caries are the top reason for hospital admissions for children aged 1-18 years in the borough Dental caries are responsible for 19% of hospital admissions in 5-9 year olds(2012-13). Access and uptake of dental services: Individuals and families may access primary care dental services where ever they wish and are not constrained to access care within the Borough of where they reside or are registered with a GP. In general, uptake of dental services for children (1-17 years) in Hounslow at June 2013 given as attending a dentist in the 24 months preceding June 2013 is 72.2% and is better than the averages for London (63.1%) and England (69.1%). However, uptake rates have plateaued over the last 2 years.

Dental Attendence (%) Percentage (%) Child Dental Uptake Rates 2011-2013 It is recommended that children make their first visit the dentist within 6 months of the eruption of their first tooth (which occurs at around 6-9 months).the chart below shows that the low percentage of children in Hounslow who visited the dentist within 24 months aged 0-2 years 80.0 75.0 70.0 65.0 60.0 55.0 50.0 45.0 40.0 Mar-11 Mar-12 Mar-13 Hounslow 59.6 61.0 61.1 London 56.9 58.3 58.8 England 68 72 72 The highest percentage of children in Hounslow who visited the dentist within 24 months were aged 6-12 years At each age group Hounslow was above the London average for dental attendance. Child dental attendance rates by patient residence in the past 24 months by age groups (September 2013) 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 0 to 2 Yrs 3 to 5 Yrs 6 to 12 yrs 13 to 17 yrs Fluoride varnish applications Hounslow 14.5 57.7 87.0 73.1 London 13.0 54.8 79.5 71.6

Percentage (%) There is strong evidence to support the application of fluoride varnish at least twice a year for children over 3 years of age and 3-4 times for those at higher risk. Fluoride Varnish rates per 100,000 courses of treatment for children 0-19years between 2011-2013 per Patient Residence Location (Hounslow ) 2011-12 2012-13 2013-14* London 10.0 16.6 22.6 Hounslow 16.8 20.4 26.7 Fluoride Varnish Rates 2011-14 per 100,000 CoT based on Patient Residence Area (Hounslow) 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 2011-2012 2012-2013 2013-2014 London 2013-2014 3-5 YEAR OLDS 18.2 22.5 29.2 23.6 6-9 YEAR OLDS 20.2 25.1 32.3 28.8 10-15 YEAR OLDS 16.8 20.8 28.7 24.8 The data shows year on year there has been an increase in fluoride varnish applications on Hounslow children s teeth The largest proportion of children receiving fluoride varnish are within the 6-9 year olds It should be noted that there is an incomplete data set for 2013-14, which will be completed at March end 2014* and reported later in 2014 What works in tackling this issue: For the most sustainable gains in oral health and reductions in inequalities: Interventions should tackle the social determinants of health, adopting a whole population approach with varying degrees of effort and intensity depending on level of disadvantage. The Marmot Review coined this proportionate universalism. xv Oral health efforts should not be carried out in isolation but should be integrated with broader children s and public health programmes such as those tackling obesity,

improving diet and lifestyles, breastfeeding and weaning xvi, following a common risk factor approach. Interventions should start at an early age and continue throughout the life of a child, because what happens in early childhood has an impact on later life (life course approach). xvii Sustainable improvements can be achieved by improving diet and reducing sugar intake xviii xix encouraging preventive dental care and increasing the use of fluorides. The almost universal use of fluoride toothpaste is one of the main reasons for improvements in oral health over the last thirty years. xx Children should be encouraged to brush their teeth twice a day with a tooth paste containing an appropriate level of fluoride xxi to spit out the paste and not rinse and there should be supervision until at least the age of 7 years. Children who start brushing with fluoride toothpastes in infancy are less likely to experience tooth decay than those who start bushing later, by stimulating healthy dental behaviour from a young age. For children with active caries over 10 years of age, 2800ppm fluoride toothpaste and over 16 years 5000ppm fluoride toothpaste is available on prescription. Fluoride varnish application to the teeth of children should be at least twice a year, as this substantially reduces tooth decay in children xxii,xxiii and 3-4 times for those at higher risk delivery programmes have also been shown to be beneficial in reducing tooth decay, based on studies from systematic reviews and randomised controlled trials - fluoride varnish is a concentrated topical fluoride with a resin or synthetic base, designed to prolong the contact time between fluoride and dental enamel. xxiv xxv A Cochrane Review concluded that the application of fluoride varnish by dental professionals was associated with a 46% reduction in decayed, missing, filled surfaces in children. xxvi Regular supervised use of fluoride mouth rinses may be prescribed for children wearing orthodontic appliances at a different time to brushing with fluoride toothpaste or others at high risk of dental caries as this will reduce tooth decay xxvii Where appropriate, dentists are recommended to cover the occlusal surfaces of molar teeth of children with a resin-based sealant as they are less likely to get dental decay in their molar teeth than children without a sealant 7xxviii What are we doing in Hounslow to tackle this issue: Work is continuing within Hounslow to implement the recommendations of the North West London Child Oral Health Improvement Strategy (2011-16), across three overarching priority areas: Making oral health everybody s business and every contact count Integration of oral health with other Public Health and Children s Programmes Increasing children s exposure to fluoride This strategy and the Hounslow children and young people s oral health improvement plan aligns with recent national guidance for Local authorities in their Commissioning Better Oral Health (2014) xxix and will enable: Hounslow children to receive oral health advice from all health practitioners to make every contact count, including School Nurses, Health Visitors, Early Years and Children s Centre staff, Health Trainers, Foster Carers etc.

Health and non-health practitioners to promote the Brushing for Life Programme (toothpaste and brush packs) and Healthy teeth, Healthy Smiles Hounslow leaflets, to encourage registering/attending a dentist regularly, seeking Fluoride Varnish application and receiving advice on good eating/drinking habits and tooth-brushing Delivery of an enhanced DEP survey 2014 of the oral health of all 5 and 12 year olds in Hounslow s special schools Explore delivery of an enhanced survey of 5 year olds to provide ward level data to better gauge state of our child oral health across the borough, and assess where to focus any targeted action

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xxix Commissioning Better Oral Health (2014) https://www.gov.uk/government/publications/improving-oral-health-an-evidence-informedtoolkit-for-local-authorities